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At least 16% of the U.S. population has no health insurance.1 Uninsured patients can pose problems in NP practice because they sometimes ask for favors that create legal or ethical risks. This article describes an example of the ethical and legal compliance issues NPs grapple with while trying to do good for patients.

Ethical choices always seem most difficult when doing the right thing appears to require doing the wrong thing. This dilemma underlies the actions of all who do harm to serve what they view as the greater good. Breaking "bad" laws through civil disobedience has been part of social progress in the 20th century. How do health care providers serve the needs of their uninsured patients - including and especially innocent children - while complying with the law?

Case Study
"Rhonda" is a 6-year-old girl with moderate persistent asthma. Her disease is managed using a long-term beta agonist and an inhaled steroid. She uses albuterol only when the asthma symptoms become uncontrollable, which is less than once every 6 months. Rhonda's mother is compliant with the prescribed medical care, and the child is generally happy and healthy. Her illness is well controlled.

Rhonda has a 15-year-old sister with a history of mild intermittent asthma. Her symptoms have been well controlled for 3 years. The NP has known Rhonda's mother for 15 years, and they have a strong professional relationship. Their interactions are based on mutual respect and trust.

Rhonda's mother has been the sole supporter for the child since her divorce approximately 4 months earlier. She recently lost her job as a secretary and now works as a housekeeper. The mother has applied for, but not yet received, health insurance for Rhonda.

Rhonda had an asthma attack last night and visited the emergency department for care. She now requires a prescription for albuterol. Rhonda's mother cannot receive health insurance reimbursement for the medication if the prescription is written for Rhonda. The mother requests that the drug be prescribed in the name of the 15-year-old sister, who is covered by insurance.

The NP is aware of the financial hardship the family has faced over the past year. She is also aware that the sister already takes the same medication. Her instinct is to write the prescription the mother desires. What is the harm in doing a favor for the good of the patient? What should the NP do?

Discussion
Ethical and legal issues sometimes conflict, yet overlap. It would be faulty thinking to assume that writing this prescription is within ethical standards because the mother has applied for health insurance and the child is in obvious need of medication.

Despite the knowledge that insurance paperwork process is tedious and delayed, the NP should neither write the prescription for someone other than the patient nor leave the patient name blank. Falsifying the document may seem like the right thing to do to combat the faults of the health care system, but truthfulness is the basis of the patient-provider relationship and must be preserved. Although she feels a higher ethical motive for the good of the patient, the NP cannot meet that good for social and economic reasons. While the patient is the No. 1 priority, the NP cannot fix the health care system by skirting the law.

Competencies for nurse practitioners are clearly outlined and integrated into NP educational programs, and guidelines encompassed in these competencies state that NPs should act ethically in meeting the needs of patients.2 Many NP graduate programs do not include ethics classes, yet ethical dilemmas are frequent in actual practice. These questions arise as often in outpatient settings as they do in the hospital. In fact, within the privacy of a closed-door exam room, breaches in professional behavior are actually higher.3 The private office is often viewed as a safe place since there are fewer employees and less monitoring, leading to protected communication.

Legal and ethical issues sometimes conflict.4 Abortion and assisted suicides are specific areas where the ethical questions are circumscribed by law. Prescription writing is regulated by law. NPs must follow the law first and then ponder the ethics of their actions. Writing a prescription in another person's name is defrauding an insurance company. While it would seem that writing a prescription is a private event, since it is governed by law, it is also a public action. The concept of beneficence - acting for the good of the patient and as the patient's advocate in the face of obstacles - is not an acceptable defense.

Writing a falsified prescription is a violation of the Health Care Fraud Act. A professional who becomes aware of a falsified prescription must report it to the appropriate state agency. Civil penalties can be levied by the state Board of Nursing against an NP who falsifies a prescription.

Professional competency is based on truthful, ongoing, respectful therapeutic interaction that follows both ethical principles and the law. While it may be difficult to say no to Rhonda's mother, it is clearly necessary.

So how can the nurse practitioner help Rhonda and also remain legally correct? The table accompanying this article shows resources that can assist patients. Community emergency plans, pharmaceutical company representatives, samples, prescription price comparisons, and family financial sources are just some of the ways NPs can help meet patients' needs.

Putting It Into Practice
Patient advocacy is the lifeblood of every nurse practitioner. Navigating the difficult waters of today's complex health care system requires knowledge, persistence and compassion.

Although the system requires change to best serve patient needs, NPs cannot risk attaching the higher ethical motive of beneficence to feelings of advocacy. To do so would break the law. Truly doing good for the patient means holding yourself to the ethical standards of a consummate professional.

Ritamarie John is a pediatric nurse practitioner with a doctorate in nursing practice. She is an assistant professor of clinical nursing at Columbia University in New York City.

References
1. National Coalition on Health Care. Facts on health insurance coverage. Available at: http://www.nchc.org/facts/coverage.shtml. Accessed July 27, 2007.

2. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Primary Care Competencies in Specialty Area: Adult, Family, Gerontological, and Women's Health. Available at http://www.nonpf.com/finalaug2002.pdf. Accessed April 1, 2007.

. Gallagher T. Medical errors in the outpatient setting: ethics in practice. J Clin Ethics. 2002;13:291-299.

4. DeVille K. Act first and look up the law afterward? Medical malpractice and the ethics f defensive medicine. Theor Med Bioethics. 1998;19:569-589.




     

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